When Insurance Companies Decide What Care Looks Like

Over the last few months, I have been speaking more openly about what is happening behind the scenes with insurance companies and the direct impact it is having on mental health care in our communities. This is not political. It is not dramatic. It is not a publicity move. It is a response to what I am witnessing in real time as a clinician, a practice owner, and an advocate for access to care.

Here in Arizona, Blue Cross Blue Shield has implemented significant changes to who can provide services, how those services are delivered, and what they deem reimbursable. These decisions are being made by a corporation, not by the Arizona Board of Behavioral Health Examiners, which is the regulatory body created to determine who is qualified to practice and under what standards. Yet insurance companies are increasingly overriding those standards and redefining what “quality” or “necessary” care looks like.

As a result, we have had to stop offering certain much needed services through BCBS. Not because those services were inappropriate. Not because they were ineffective. But because the insurance company changed the rules in ways that made it unsustainable and professionally conflicting to continue under their terms. When that happens, access to care shrinks. Especially in rural and underserved areas where families rely heavily on insurance because private pay simply is not an option.

At the same time, insurance companies publicly claim they are expanding access and improving care. Yet providers are leaving networks. Restrictions are tightening. And patients are being funneled toward internal provider networks where choice becomes limited and assignment replaces autonomy. Value based care models are being introduced that cap the number of sessions allowed regardless of the complexity of someone’s trauma, history, or circumstances. You become a diagnosis code. You are allotted a number of sessions. You are expected to improve within that framework.

If you do not, the system often shifts toward medication management rather than deeper therapeutic work. And if the medication is too expensive, unavailable, or produces side effects that are intolerable, that becomes another barrier the individual must navigate alone.

Then came the audit.

Insurance audits are typically limited to one year unless there are concerns regarding fraud, waste, or abuse. My audit goes back to 2022. Nearly every chart requested involves associate clinicians. Many of those clients were seen for fewer than ten sessions over a six month period. Not excessive use. Not back to back daily sessions. Under ten sessions across half a year.

There have been no specific allegations provided. No defined examples of wrongdoing. Simply a statement that concerns exist.

Now I am required to turn over full client records. Intake paperwork. Assessments. Diagnoses. Treatment plans. Progress notes. Discharge summaries. The entirety of someone’s mental health journey, reviewed years later by individuals who have never met these clients and do not work in the therapy room.

If they determine that something was not “medically necessary,” or if documentation was signed outside of an arbitrary timeframe, they can demand repayment. Years later. From a small private practice.

While I sit through this process, I cannot ignore the timing. This audit was initiated after I publicly spoke about the impact BCBS changes were having on access to care. That may be coincidence. But it is difficult not to question.

And it is not just one insurance company.

Aetna clawed back ten thousand dollars directly from my account. Not a future offset. Not a warning. They withdrew the funds. They later admitted the clawback was done in error. Yet despite months of providing documentation and follow up, that ten thousand dollars has not been returned. I am still out that money while I continue to fight for it.

Meanwhile, insurance companies demand immediate responses from providers. Strict deadlines. Rapid compliance. Quick turnaround on documentation. Everything must be submitted promptly when it benefits them. But when they make an error that financially harms a small business, repayment drags on for months.

How is that equitable?

How is that ethical?

Insurance executives earn millions of dollars annually while families struggle to afford rising premiums and high deductibles before coverage even begins. Practices are expected to absorb inflation, increasing overhead costs, continuing education requirements, and the risk of audits and clawbacks, all while reimbursement rates stagnate or decrease.

This is not about protecting patients. This is about protecting profit margins.

The deeper I look, the clearer it becomes that this is not isolated to one carrier. Insurance companies are building internal provider networks. They are assigning clinicians. They are shifting toward value based payment models that limit session counts and reduce individualized care. And they are tightening administrative oversight in ways that disproportionately burden independent practices.

If private practices cannot sustain this level of risk, they will stop accepting insurance. Many already have. When that happens, the very people insurance claims to serve are left with fewer options and longer wait times.

This is not just impacting me as a business owner. It will impact anyone who relies on insurance for mental health care. It will impact rural communities. It will impact families who cannot afford to pay out of pocket. It will impact clinicians who want to stay in network but cannot survive under these conditions.

The Arizona Board of Behavioral Health Examiners exists to ensure we practice ethically and competently. We complete years of education, supervised hours, examinations, and ongoing continuing education. Insurance companies are businesses. They are not regulatory boards. They are not clinical authorities. Yet they are increasingly dictating what care looks like.

I know that insurance companies will not change without pressure. That pressure has to come from members, from communities, and from lawmakers willing to examine the imbalance of power that currently exists. We need transparency. We need accountability. We need clearer legal boundaries around how far insurance companies can go in overriding professional regulatory standards.

Most importantly, we need real access to care.

With everything happening in the world, mental health support should be expanding, not contracting. Care should be individualized, not reduced to a session cap. Oversight should ensure quality, not intimidate small practices.

This is why I continue to speak. Not because it is comfortable. Not because it is profitable. But because what is happening now will shape what mental health care looks like for years to come.

This is not just a provider issue. It is a community issue. And communities deserve to know.